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This UCSF Doctor Has a Radical Approach to Breast Cancer

Oncologist Laura Esserman says that screening is pressuring too many Stage 0 patients into surgery too soon.

 

When doctors drop the C word, many patients automatically assume that they’re going to die. Courtney Hollander, however, wasn’t one of them. When her gynecologist gave her the news that she had ductal carcinoma in situ (DCIS), sometimes called stage 0 breast cancer, she wanted to consider her options and weigh their risks. Instead, she was told that she needed surgery within eight weeks. “I wasn’t comfortable at all with having a double mastectomy when I didn’t have invasive cancer,” Hollander says. “Because I wasn’t basing my own approach to cancer on fear, I was very frustrated by doctors who said, ‘We’ll remove your breasts, and you won’t have to be afraid.’”

So Hollander turned to the Internet and found Dr. Laura Esserman, a UCSF breast oncologist who believes that doctors are screening too aggressively, biopsying too frequently, and performing too many unnecessary mastectomies. “It’s torture for people,” Esserman says. “Patients are being pushed into the operating room. We need to rethink what the goal of screening should be.” 

Back in the ’80s, when oncologists were seeing too many patients come in with deadly late-stage breast cancer, they pushed for more screening, hoping that catching and treating breast cancer earlier would save lives. Thanks to advanced mammography, MRIs, and awareness campaigns, the number of patients diagnosed with DCIS has exploded, from around 7,000 cases in 1980 to about 60,000 today, accounting for approximately 25 percent of all breast cancer diagnoses.

DCIS isn’t life-threatening on its own, because the cancer cells are contained entirely within the milk ducts. It does, however, increase a patient’s chances of developing invasive cancer later, so the standard treatment has been to remove it via lumpectomy, mastectomy, or double mastectomy.

If all breast cancers were created equal, Esserman says, catching DCIS early and removing breast tissue should reduce the number of patients who develop invasive breast cancer. But it doesn’t. Last October, a study published in JAMA Oncology found that women who have been diagnosed with DCIS are no more likely to die from breast cancer than women who don’t have the disease. 

While there are undoubtedly cases of DCIS that do require more treatment—patients with a family history of invasive breast cancer, women who have DCIS with features that increase its potential to grow—Esserman argues that many women with DCIS can afford to take the active surveillance approach, trying hormone therapy and other treatments before resorting to surgery. It’s the option that Hollander chose after meeting with Esserman. Though surgery was still on the table, Esserman told Hollander that she had the time to enroll in a clinical trial testing the efficacy of the drug tamoxifen in treating DCIS. Six months in, they’d do an MRI and see if they could avoid surgery.

In the American oncology world, opting for active surveillance is a radical approach, says Dr. Mehra Golshan, distinguished chair of surgical oncology at Brigham and Women’s Hospital in Boston. “I may not be as far along as Dr. Esserman in terms of my comfort level about the number of women who can be treated this way,” he says, “but I do believe there is a significant minority of women who only require active surveillance. The question is, which women?”

It’s a good question, one that Esserman is hoping she can help answer. Already the oncologist has set up a registry of DCIS patients across the five UC med centers, tracking which treatment they choose and monitoring their outcomes. She is also spearheading the WISDOM study, which will follow 100,000 women to see if taking a risk-based approach to individual screening schedules is more effective than setting generic standards based on age (the study subjects will have the option to choose which approach they prefer).

Golshan believes that studies like Esserman’s, along with a 10-year-long randomized DCIS treatment study called LORIS that’s under way in the U.K., will provide enough data within three to five years to determine which subset of women with DCIS can afford less treatment. “Do I agree with everything Esserman does? No. But I think what she’s doing to question treatment is great.”

So does Hollander, even though her six-month run with tamoxifen was unsuccessful. Last fall, she began preparing to go in for her mastectomy. Then, at 10 p.m. on a Saturday night, Esserman called to give her one more option: three months on a more powerful drug. If it fails, Hollander will go under the knife this month.

“At first I thought, am I crazy?” Hollander says. “But it’s not like I went to an ashram in India to cure my cancer. I’m deep in the bowels of the medical world, with people who are highly skilled and competent. It’s incredible to feel empowered instead of afraid.”


Originally published in the January issue of
San Francisco

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